DAFNE

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DAFNE!
Dose Adjustment For Normal Eating
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A new approach to diabetes
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Key Criteria for Structured Education

• A structured curriculum person centred
  and evidence based, using adult learning
  principles and supporting materials
• Trained educators
• Quality assured, looking at environment,
  structure, process, content and outcome
• Auditable biomedical, quality of life, patient
  experience.

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THE DAFNE PREMISE
Type 1 diabetes is an insulin deficiency disorder

• In order to manage blood glucose people need to
• Anticipate the effect of lifestyle on blood
  glucose
• Adjust their insulin to match their lifestyle
  

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DAFNE Philosophy

• To manage blood glucose levels, individuals need
  skills to anticipate the effect of lifestyle
  choices on their blood glucose and adjust their
  insulin to manage this
• To develop skills, individuals require
  opportunities to experiment, practice and reflect
  on what has happened to make the most of learning
• Skills training can empower the individual to
  self manage their diabetes

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Adult Education Principles

• DAFNE participants already have a wealth of
  experience 130 years on one course
• Provide opportunities for the group to learn from
  each other
• Use a range of teaching methods to allow
• -Experimentation
• -Practise skills
• -Reflection
• Let participants have as much control as possible
• Provide opportunities for feedback
• Create a climate that is non-threatening and
  relaxed

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What is taught?
Carbohydrate counting 10g CHO 1
CP Insulin adjustment 1u I
1 CP initially Amongst other things!!!
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Also taking into consideration
Exercise Snacks Alcohol
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DAFNE Timetable
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Carb counting

• 10g carbohydrate 1 carb portion 1 CP
• 15g carbohydrate 1 ½ carb portions 1 ½ CP
• 20 g carbohydrate 2 Carb portions 2 CP
• Etc!!

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How does this affect BG?

• 1 CP increases BG by 2 3 mmols
• 1 u Insulin decreases BG by 2 3 mmols
• DAFNE Targets-
• Breakfast 5.5 - 7.5 mmols
• Other meals 4.5 - 7.5 mmols
• Before bed 6.5 8.0 mmols

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Ratios

• We start with a ratio of 11 1 unit Insulin for
  every 1 CP
• Eg. Breakfast 1 cup Branflakes (7 tbs) 1 cup
  milk
• 1 bagel butter 1
  tsp jam
• Work out CPs and how much insulin to take on a
  11 ratio
• 3 1 4 1 9

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What to do when out of target

• BG is 10 mmols at Breakfast. I eat 6 CPs and my
  ratio is 11. How much insulin should I take?
• 10 is 2.5 above target, therefore take 1 unit
  extra, i.e. 7 u insulin with breakfast

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Background Insulin Tips

• The ideal amount of background insulin (BI) is
  one that keeps the fasting blood glucose (BG)
  level within the target range.
• Indications that the BI is too high include
• Any low BG level during the night and before
  breakfast
• Unexplained lows during the day when a meal is
  delayed or skipped.
• Indications that the BI is too low include
• Elevated fasting or 3.00am BG values with normal
  bedtime BG value
• Increased BG when a meal is skipped or delayed.

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Reassessing BI

• Think about reassessing BI for
• Sustained changes in activity
• Changes in weight
• Illness
• New medication (steroids)
• Menses
• Pregnancy

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DAFNE OUTCOMES

• Evidence over 20 years different countries
• Better Outcomes
• - lower HbA1c
• - No increase in severe hypoglycaemia
• -choice over weight
• - freedom to eat
• - high treatment satisfaction

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Mean HbA1c
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HbA1c Decrease of gt 1
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Case Study 1
All names have been changed to protect the
innocent! Raj, 35 y Type 1 Dm 20 y. On
steroids for polymyositis, was on bd mixed
insulin. Lots of highs and lows. Steroid dose up
and down. Losing weight Dafne course Feb. 04,
HbA1c 8.3, wt 66kg ht 185cm BMI 19 Changed
to basal bolus regime By Sept. 05, HbA1c 6.2, wt
74kg BMI 22 Regular discussions via electronic
diary, to help with decision making
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Case Study 2
Janice 34y Bd insulin, wants a baby! Dafne
course May 03 HbA1c 7.0 Change to basal bolus
regime 5 injections, Pregnant January 04,
HbA1c 6.7 April 04 HbA1c 6.1
September 04 HbA1c 6.5 healthy baby
But by February 05 HbA1c 8.7!!!!!
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Case Study 3

• Chris age 42, diabetes 12y, drives long
  distances to work, so eats to avoid hypos,
  rarely tests.
• DAFNE course Dec 04
• - HbA1c 7.7, wt 87kg
• By October 05
• - HbA1c 6.7, wt 84kg
• I feel in control for the first time since
  diagnosis!

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Funding???

• From 2006, all PCTs have had to commit (?) to
  offering quality, evidence-based structured
  education programmes to all people with diabetes
  from the point of diagnosis.
• Funding is the big issue- No-one wants to pay!
• Everyone benefits the trainers, the service,
  more resources and most of all, the empowered
  patient
• Fact these courses are a pleasure to teach!
• T1EN providing DAFNE- type courses in other
  ways InSight, Bertie, Charlie!

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Key Points

• All people with Type 1 diabetes should be offered
  a structured education course
• The service should be structured so that newly
  diagnosed type 1s are offered the course within
  a year of diagnosis
• The different actions of QA insulin and BI need
  to be understood
• Carbohydrate counting is an important skill for
  all involved
• Lifestyle choices such as exercise and alcohol
  need to be considered
• Dafne skills of matching insulin to carbs and a
  knowledge of healthy eating are the ideal!